ASAIO journal : a peer-reviewed journal of the American Society for Artificial Internal Organs
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The potential for long-term support on a ventricular assist device (VAD) in the bridge-to-transplant (BTT) and destination therapy (DT) settings has created unprecedented ethical challenges for patients and caregivers. Concerns include the patient's adaptation to life on a device and the ethical, clinical, and practical issues associated with living on mechanical support. ⋯ Patient preparation for VAD implantation encompasses three phases: 1) initial information regarding the physical events involved in implantation, risks and benefits of current device technology, and the use of VAD as a rescue device; 2) preimplant preparation including completion of advance directives specific to BTT/DT, competency determination, and identifying a patient spokesperson, multidisciplinary consultants, and cultural preferences regarding device withdrawal; and 3) VAD-specific end-of-life issues including plans for device replacement and palliative care with hospice or device withdrawal. This three-phase 10-point model addresses the ethical and psychosocial issues that should be discussed with patients undergoing VAD support.
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We report a case of severe posttraumatic acute respiratory distress syndrome (ARDS) complicated by bronchopleural fistulae (BPF). The stiff ARDS lung and huge air leaks from BPF resulted in the failure of different protective mechanical ventilation strategies to provide viable gas exchange. Lung rest, achieved by extracorporeal carbon dioxide removal (ECCO₂R), allowed weaning from mechanical ventilation, closure of BPF, and resumption of spontaneous breathing.
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Multicenter Study
Antimicrobial prophylaxis and infection surveillance in extracorporeal membrane oxygenation patients: a multi-institutional survey of practice patterns.
The goal of this study was to characterize antimicrobial prophylaxis and infection surveillance practices at centers treating patients with extracorporeal membrane oxygenation (ECMO). A 37-question web-based survey was sent to all ECMO coordinators and directors at Extracorporeal Life Support Organization (ELSO) participating centers. Data were reported by center. ⋯ There is significant variation in the antibiotic choices and duration of prophylaxis, regardless of whether the center has a protocol or not. Almost half of centers (49%, 64/132) perform routine surveillance cultures but at variable intervals. There is significant heterogeneity in antibiotic prophylaxis and infection surveillance practice patterns among ELSO centers.
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Controlled Clinical Trial
Addition of acetylsalicylic acid to heparin for anticoagulation management during pumpless extracorporeal lung assist.
Pump-driven extracorporeal membrane oxygenation (ECMO) or pumpless arterio-venous interventional lung assist (iLA) is associated with possible complications, mainly consisting of bleeding or thrombosis/clotting by cellular deposits on the membrane or extracorporeal circuit surfaces, which may reduce gas-exchange capacity. In this study, we report our experiences with the addition of low-dose acetylsalicylic acid (ASA 1.5 mg/kg body weight/d) to heparin for anticoagulation of a pumpless low-resistance gas-exchange membrane (Novalung GmbH, Talheim, Germany). We assessed changes in coagulation parameters and the demand for transfusion of blood components. ⋯ The use of membranes per patient (membrane/patient ratio) tended to be decreased in patients treated with ASA (1.12 ± 0.34) in comparison with control (1.33 ± 0.62, p = 0.157). In the ASA group, one patient died due to multiple organ failure, whereas in the control group, five patients died. We conclude that supplementation of low-dose ASA during pumpless extracorporeal lung support is safe and might preserve the function of oxygen transfer.
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Correct placement of the Avalon Elite Bicaval Dual Lumen catheter (Avalon Laboratories, LLC, CA) for single-site venovenous extracorporeal membrane oxygenation (VV ECMO) is safe using image guidance. Using this technique, 26 of 27 patients (96%) had uneventful placement of the cannula in the right internal jugular vein. ⋯ As proficiency improves, TEE at the bedside provides an excellent standard of care. Double-lumen ECMO catheters can be effectively placed under image guidance with minimal need for repositioning.